Lumbar stenosis case (MT-ULBD) Case for plenary or small group discussions MISS Curriculum Taskforce Roger Härtl July 1, 2019 2019 and 2020

Learning objectives Describe the indications and how to select the correct patient Discuss the decision-making process for the specific procedure Outline important aspects of performing the procedure Recognize possible complications and how to avoid and manage them

Presentation 82-year-old woman presents with tingling and burning sensation in her legs when standing and walking Develops heaviness and buttock and bilateral leg pain when she walks; she can only walk a few blocks Sitting down relieves the pain No mechanical back pain with flexion and extension Past medical history: Coronary artery disease with stents, on blood thinners, medication controlled diabetes mellitus, otherwise healthy Neurological examination: intact, vascular examination normal (pulses) Discuss the exam of the patient: /what do you do in the office and what do you ask for? How to differentiate between different types of pain: radicular, mechanical and neurogenic claudication. What maneuvers do you perform when you examine the patient? Rule our hip and knee pathology, check pulses etc. Stationary bike: no problem. Denies bowel or bladder problems. Diagnosis: vascular claudication without mechanical back pain

Imaging R foramen Left foramen Discuss imaging: DDD, grade I spondylolisthesis L4/5 and L5/S1, disc collapsed, facet angle L4/5 relatively high (steep), no foraminal stenosis Discuss indication of other imaging: CT, scoliosis films, CT myelogram, F/E films etc.

Previous treatment 3 months of physical therapy Had 2 epidural injections within last year with transient pain relief Saw 2 other surgeons and wants to discuss surgical options Failed nonoperative treatments

Flexion/extension films No movement

Diagnosis L4/5 spondylolisthesis and stenosis Neurogenic claudication Failed nonoperative treatments

Management plan/options Nonoperative treatment Physical therapy, pain management Surgery Interspinous spacer Laminectomy Open vs MIS tubular: ULBD Endoscopic Decompression and fusion MIS TLIF LLIF OLIF Others?

Treatment L4/5 MIS laminectomy (right side incision/ULBD) Discuss positioning, OR set up How to localize

“Over the top” contralateral decompression Key is to achieve a good over the top bilateral decompression

Outcome Surgery time skin to closure 45 minutes Minimal blood loss One night in the hospital because of her preoperative morbidities Neurologically intact after surgery Postoperative muscle spasms treated with muscle relaxants, subsided after a few days Walking improved

MISS tubular surgical options MIS tubular microdiscectomy (MCD) MIS tubular foraminotomy MIS tubular laminotomy or bilateral laminectomy: ULBD MIS tubular resection of synovial cyst MIS tubular fusion (as part of MIS TLIF) MIS tubular spinal canal tumor resection These are other indications for tubular decompression

Patient selection Patient complaints vs patient imaging Stability Canal stenosis Foraminal stenosis (unilaeral and/or bilateral) Previous surgery

Complications Dural tear and cerebrospinal fluid (CSF) leak Size of leak? If nerve root exposed it should be reinserted and primary closure considered May require special needle holder, knot pusher, suture Neural injury—very rare In cases with severe stenosis and calcification where the root is manipulated Usually transient weakness Infection—very rare Postoperative muscle pain/inflammation Muscle relaxants, oral steroids sometimes Meticulous hemostasis Consider epidural steroids before closure

Take-home messages MIS laminectomy via tubular retractor is safe and effective Can address bilateral pathology via unilateral approach Can preserve stability and avoid fusion Adherence to strict MIS techniques minimizes complications such as CSF leak, neural/vascular injury, infection, etc